1 Student Support Scheme for those in the International Protection System 2021 Application Form Applicants Full Name (in block letters) For Official Use Only SSS Ref No: CLOSING DATE: 30 th November 2021 Please read the Guidance Notes 2021/22 regarding eligibility criteria carefully before completing this form. A copy of the Guidance Notes is available on the following link. gov.ie Student Support Scheme for those in the International Protection System 2021 (www.gov.ie) Depending on your circumstances, Higher Education – Equity of Access (HEEA) may agree to accept your application after the closing date. Please answer all questions. If a question or section does not apply to you, please enter ‘N/A’ (not applicable). If you need further advice or support filling in this form, please contact HEEA support desk by email at [email protected]. You must return your completed application form and documentary evidence to HEEA Section by email to: [email protected]
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Student Support Scheme for those in the International Protection System 2021
Application Form
Applicants Full Name (in block letters) For Official Use Only
SSS Ref No:
CLOSING DATE: 30th November 2021
Please read the Guidance Notes 2021/22 regarding eligibility criteria carefully before completing this form. A copy of the Guidance Notes is available on the following link. gov.ie Student Support Scheme for those in the International Protection System 2021 (www.gov.ie) Depending on your circumstances, Higher Education – Equity of Access (HEEA) may agree to accept your application after the closing date.
Please answer all questions. If a question or section does not apply to you, please enter ‘N/A’ (not applicable).
If you need further advice or support filling in this form, please contact HEEA support desk by email at [email protected].
You must return your completed application form and documentary evidence to HEEA Section by email to:
A3. Your title: Mr. Mrs. Ms. Other (Please Specify)
A4. Your surname:
A5. Your first name(s):
A6. Your first name as it appears on your birth certificate:
A7. Your birth surname:
A8. Your mother’s birth surname:
A9. Your date of birth:
A11. Your current address:
A12. Your telephone numbers:
A13. Your email address:
A14. Category of Student dependent on parent(s)/
Applicant:
Mature student dependent on pa
Independent mature student
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legal guardian
rent(s)/legal guardian
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A15. Are you: (please tick) Single (never married) Married/in a civil partnership
Cohabiting Remarried
Separated Divorced/Former civil partner
Widowed/Surviving civil partner
B – Nationality and Residency
B1. What country were you born in? Ireland Elsewhere
If Ireland, enter the county:
If elsewhere, enter the country:
B2. What is your nationality?
B3. What is the basis of your permission to reside in the state? (please tick)
(Documentary evidence required) Tick
a) International Protection applicant;
b) Subsidiary protection applicant;
c) Leave to remain stage (other than those at deportation stage)
(Please Note: If you are not one of the above 3 categories, you are not eligible for support).
B4. Date of entry to the State;
B5. Date application made to D D M M Y YIPO (ORAC)
(Documentary evidence required)
IPO (ORAC) application reference number:
B.6 Have you been resident in Ireland for at least the last 3 years Yes No as at the 31st August 2021?
(Documentary evidence required)
C – 2021/22 Course details and academic history
D D M M Y Y
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C1. Have you secured an undergraduate course Yes No Through the CAO application process?
(Documentary evidence required)
CAO ID Number
C.2. Which type of full-time course PLC NFQ Level 5 or equivalent
do you wish to pursue in the 2021/22 academic year? PLC NFQ Level 6 or equivalent
NFQ Level 6 (Higher Certificate) or equivalent
NFQ Level 7 (Ordinary Degree) or equivalent
NFQ Level 8 (Honours Bachelor Degree) or equivalent
NFQ Level 9 /10 (Post-Graduate/Masters/ Doctorate) or equivalent
Institution Name:
Course:
Course Code:
Course Start Date:
Is this a full-time course? Yes No
Which year of the course will you be enrolling e.g, 1st Year, 2nd Year:
Is this course an add-on course? Yes No
C3. Have you previously attended a course of further Yes No or higher education?
a) If Yes, was your previous attendance on a Yes No PLC course?
b) If Yes, was your previous attendance on an Yes No Undergraduate course?
c) If Yes, was your previous attendance on a Yes No Postgraduate course?
If you have answered yes to any of the above, please enter the details below:
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Type of course PLC NFQ Level 5 or equivalent
PLC NFQ Level 6 or equivalent
NFQ Level 6 (Higher Certificate) or equivalent
NFQ Level 7 (Ordinary Degree) or equivalent
NFQ Level 8 (Honours Bachelor Degree) or equivalent
NFQ Level 8 (Higher Diploma) or equivalent
NFQ Level 9 (Postgraduate Diploma) or equivalent
NFQ Level 9 (Masters Degree)
NFQ Level 10 (PHD)
Title of course
a) Name of college or Institution
b) Address of college or institution
c) On what basis did you attend this course? Full-time Part-time
d) Start date of the course
e) Did you complete the course? Yes No
f) If yes, what qualification did you receive?
g) When did you leave, finish or last attend this course?
h) Will you be continuing on this course Yes No in 2021/22
i) What year of the course did you last attend?
Additional courses:
a) Type of course PLC NFQ Level 5 or equivalent
PLC NFQ Level 6 or equivalent
NFQ Level 6 (Higher Certificate) or equivalent
NFQ Level 7 (Ordinary Degree) or equivalent
NFQ Level 8 (Honours Bachelor Degree) or equivalent
NFQ Level 8 (Higher Diploma) or equivalent
NFQ Level 9 (Postgraduate Diploma) or equivalent
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NFQ Level 9 (Masters Degree)
NFQ Level 10 (PHD)
b) Title of course
c) Name of college or Institution
d) Address of college or institution
e) On what basis did you attend this course? Full-time Part-time
f) Start date of the course
g) Did you complete the course? Yes No
h) If yes, what qualification did you receive?
i) When did you leave, finish or last attend this course?
j) Will you be continuing on this course Yes No In 2021/22
k) What year of the course did you last attend?
C4. What is the full title of the highest qualification you have attained.
C5. Have you applied for or will you be getting Yes Noany other student financial assistance from Ireland or abroad for 2021/22 academic year?
If Yes, please give details of all awards/funds from the awarding/funding body including non-government organisations or Department(s) and the full amount, including fees, that you will get in 2021/2022:
D – Personal details of your parents/guardians/spouse or
civil partner
Relationship to applicant
D1. PPS No:
D2. INIS Person ID No:
D3. Date of Birth:
D4. Surname:
D5. First name(s):
D6. Mother’s birth surname:
D7. Current marital status:
Single (never married)
Married/ In a civil partnership
Cohabiting
Separated
Divorced/ Former civil partner
Remarried
Widowed/ Surviving civil partner
If you are under 23
Deceased
(tick only if both parents deceased)
Estranged
(in cases where an applicant is under 23 years of age is
living away from the family home due to circumstances
beyond the applicant’s control and estrangement can be
proven, the applicant can be assessed on their own income.
Father or
Legal
Guardian or
Foster
Parent
)
Spouse or Civil partner or cohabitant
Mother or
Legal
Guardian
Or Foster Parent
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D8. Address:
D9. Telephone numbers:
D10. Employment status:
Employed
Self-employed
Unemployed
Retired
Student
Home duties
Other (please specify)
D11. Occupation
E: Dependent Chi
Fa or
Le
Gor
Fo
P
M or
Le
G O Parent
Sp C or cohabitant
ther
gal
uardian
ster
ldren
arent
other
gal
uardian r Foster
ouse or ivil partner
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E1. If you are applying as a student dependent on parent(s) or legal guardian, or a mature student dependent on parent(s) or legal guardian please list other dependent children of your parent(s) or legal guardian and your own dependent children, if applicable. If you are applying as an independent mature student, list your own dependent children and the dependent children of your spouse, if applicable. Please give details below of dependent children (Including foster children) who, on 1 October 2020, were in the following categories. Completing this section will ensure that any potential delays will be minimised and it may be to your benefit should a grant be awarded. This may positively impact income threshold levels:
(a) under 16 years of age; (b) 16 years of age or over and in full-time education; or (c) medically certified as permanently unfit for work.
Completing this section will ensure that any potential delays will be minimised and it may be to your benefit should a grant be awarded. This may positively impact income threshold levels.
Surname First Name
Date of Birth
Category of Dependent
child: (a); (b); or
(c)
School or college this child attended
in 2020/21 (if applicable)
Relationship to the
applicant
PPS No
INIS Person ID Ref
No
E2. Please give details of the children listed above who, in the 2021/22 academic year, will attend a full-time course of further or higher education and training in Ireland.
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Surname First Name College or institution
student will attend in 2021/22
Course Title
Year of course this
student will be in
for 2021/22
Has this student
applied / or will apply
for a student grant?
Awarding grant
authority (if applicable)
F – Reckonable Income
PLPLE VERY IMPORTANT:
PLEASE SUBMIT PROOF OF ALL INCOME WITH THIS FORM: I.E. A CERTIFICATE FROM THE DEPARTMENT OF SOCIAL PROTECTION, AND PROOF OF EARNINGS IN THE FORM OF A P60 OR A CERTIFICATE FROM
THE REVENUE COMMISSIONERS.
Applicant Father or legal guardian
Mother or legal guardian
Spouse or civil partner or cohabitant
F1. Were you or your parent/guardian/spouse/civil partner or cohabitant employed in 2020 on a full-time, part-time or temporary basis?
If Yes, enter the total gross income from all employments including any benefit-in-kind in 2020
Total: €
Applican
F2. Did you or your parent/guardian/spouse/civil partner or cohabitant receive any social welfare payments in 2020?
If Yes, list the name of the payment(s) andenter the total gross amount received from 1 January 2020 to 31 December 2020
Total: €
Y
Y
Y
Total: €
t Father guardian
Total: €
Y
YN
N
T€
or legal Mgu
T€
N
N
otal:
other or legardian
otal:
N
NNY
YYY
Total: €
al Spouse partner cohabita
Total: €
YY
Y
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or civo
nt
N
N
il r
F3. Did you or your parent/guardian/spouse/ civil partner or cohabitant receive a payment from any other Government Department or State Agency, for example, the Health Service Executive (HSE), SOLAS or a local authority in 2020?
If Yes, list the name of the payment(s) and enter the total gross amount received from 1 January 2020-to 31 December 2020
Applicant Father or legal guardian
Mother or legal guardian
Spouse or civil partner or cohabitant
Total: €
Applican
F4. Did you or your parent/guardian/ spouse/civil partner or cohabitant receive any other RECKONABLE income in 2020 from any sources not mentioned above?
If Yes, please provide a description of income and enter the total gross amount paid.
Total: €
YY
Y
t
N
N
Total: €
Total: €
Total: €
Father or legal guardian
Mother or legal guardian
Spouse or civil partner or cohabitant
Total: €
N
YY Y NN N
Y
Total: €
N Y
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Total: €
N Y
N
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Checklist:
Checklist before returning the application
A. I have fully answered all questions and my parent(s) legal guardian, spouse, civil partner, cohabitant as applicable have done so as wellB. I have signed and dated the relevant declarations
C. I have submitted my basis for staying in Ireland(Question B3)
D. I have submitted my date of application made to IPO/ ORAC(Question B5)
E. I have submitted a copy of my CAO application letter (Question C4) if applicable.
F. I have submitted a certificate from the Department of Social Protection outlining any benefits that I or my family may have received in the year ending 31st, December 2020.
G. I have submitted a certificate of earnings (if applicable) of any employment or confirmation from the Revenue commissioners of my earnings for the period to 31st
December 2020.
PLEASE NOTE
It will not be possible to assess your qualification for this scheme until you have submitted all documentation requested.
F5 Did you or your or parent/guardian/spouse/ civil partner or cohabitant have a permanent change in circumstances in relation to reckonable income since 2020?
If Yes, please provide a description.
Applicant Father or legal guardian
Mother or legal guardian
Spouse or civil partner or cohabitant
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Reminder:
SIGN AND DATE THE DECLARATIONS BELOW AND ALSO ON PAGE 15
I undertake that, in accessing any courses funded by HEEA Section, Department of Further and Higher Education, Research, Innovation and Science, I will comply in full with all relevant legislation relating to my permission to reside status in the State.
In order to process your application it will be necessary for the HEEA to contact relevant higher education institutions, PLC colleges, relevant Government Departments, Agencies and other relevant bodies in order to verify the information you have provided and, in turn, to share the information you have provided.
I (Print name) …………………………….. agree to the sharing of the personal information I have provided as outlined above.
Applicant Signature_________________ Date ________________
Father or legal guardian Signature _________________ Date ________________
Mother or legal guardian Signature _________________ Date ________________
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I/We declare that all the information that I/We have given in this application is complete and accurate.
I/We will inform the awarding authority if my/our means or circumstances change.
I/We accept that failure to provide accurate information through a deliberate material omission or inaccuracy, will result in loss of support and repayment of any portion of a grant already received.
Applicant Signature_________________ Date ________________
Father or legal guardian Signature _________________
Date ________________
Mother or legal guardian Signature _________________
Date ________________
The Department of Further & Higher Education, Research, Innovation and Skills, as far as practicable and having regard to the resources available, provides for education and training for people resident in the State at a level appropriate to meet the needs and abilities of those people. The main purpose for which the Department requires the personal data provided by you is to determine eligibility for the Student Support Scheme for those in the International Protection system and to monitor and administer its payment. The personal data provided may be exchanged with the Department of Justice & Equality and Further/Higher Education institutions. The privacy notice outlining further information in relation to this form can be found at https://www.education.ie/en/The-Department/Data-Protection/gdpr/third-level-further-education-and-training/
Full details of the Department's data protection policy setting out how we will use your personal data as well as information regarding your rights as a data subject are available at https://www.education.ie/en/The-Department/Data-Protection/. Details of this policy and
privacy notice are also available in hard copy from the address above upon request.
Note: If you, your parent(s), legal guardian, spouse, civil partner or cohabitant, as applicable, fail to complete the relevant sections we will return the application form to you.
This will delay the processing of your funding application and may delay payment if your application is successful.
